The Need for Overlapping Interventions: Just One Won't Do It
Posted Jul 31 2012 10:03pm
Looking through the MRI
In a prior posting , the Disease Management Care Blog was reminded that the U.S. health care system is exceptionally complex and non-linear. Thanks to its many overlapping, contradictory, shifting and often non-medical inputs, it defies the simple logic of a single-cause-leading-to-a-single-effect. If economics is the dismal science , health care economics is its dubious spawn.
In this study, the authors examined 10 years' worth of insurance claims for advanced imaging MRI and CAT scans from two multi-state commercial insurance plans and another smaller single state plan. These data were then pooled with a 5% national random sample of imaging claims from Medicare beneficiaries. The authors also interviewed radiologists, health administrators, radiology benefit managers and physician recruiters.
The results? From 2000 through 2005, CT scans grew at a whopping rate of 14.3% but then slowed to 1.4%. MRI slowed in the same periods from 14% to 2.6%. At the same time, starting salaries for radiology specialist physicians significantly declined.
What happened? According to the authors 1. An industry sprung up. In another example of the adage that "need is the mother of invention," companies that prior authorize imaging studies for medical necessity ( for example ) were hired by many commercial insurers. They had an impact.
2. Skin in the game. Deductibles, co-insurance and co-pays made consumers think twice about agreeing to a study that was going to result in some out-of-pocket spending.
3. Unilaterally imposed fee reductions. Medicare cut the amount it paid for CAT and MRI studies performed in freestanding centers and physicians' offices. Hospitals were left untouched.
4. Glow in the dark. Media reports on the amount of radiation prompted patients to worry about the long term impact of all those x-rays.
In other words, there was no single lever. Instead, the reduction of high utilization of pricey imaging was due to the confluence of at least four mutually reinforcing trends.
As further evidence of the overlapping trends that extended beyond simple cause-and-effect, Medicare never relied on prior authorization, didn't alter the out of pocket testing expenses for beneficiaries and left the payments for hospital-based imaging untouched. Yet Medicare saw an across-the-board reduction. MRIs don't involve ionizing radiation (they use relatively harmless magnets), but their overall rate went down in concert with CAT scans..
The obvious implication for the population health management service companies is that if they're going to have a significant impact, the likelihood of a successful outcome is far greater if it is implemented concurrently with other supportive interventions.